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Please print or type, ( Form r ro ved.OMB No.2D5O-0O3D <br /> UNIFORM HAZARDOUS1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Man es Tr kin N m O 0 <br /> WASTE MANIFEST C-AR0002 x0046 � 9a-9—`a4-9988 FLE <br /> 5,Generators Name and Mailing Address Generators Site Address(If different than mailing address) <br /> CA.I.XFOR Ila HEALTH CMF FACY ITY 407650 `7707 SnUTH AUSTIN ROAD <br /> 7707 SOUTH AUSTIN R#:3aTA. (atkTa: 1.1_ S'FOC'RVI , �7A 95?V5 <br /> GTOC TON_ CA 95215 <br /> GeneratorsPhcne: 2fB'x <br /> 6,Transporter f Company Name ll'.S.EPAID Number <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8,Designated Facfliiy Name and Site Address U,S,EPA ID Number <br /> t"Fi1.In:.i5y &x O''(r>x.R'.(.ION <br /> 1636 0 W. 1.7TH TH 91TRE.T <br /> T,[ H(� -, P .AC-11, PYA 90813 <br /> Fadliry's Phone: 362-4--32-5445 C:iiDG28409019 <br /> 9a 9b.U,&DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Contalners It.Total 12.Unit 90. Codes <br /> HM and Packing Group(if any}) No. Type Quantity Wt Nol. <br /> 1.t. • d :., as a-.imirte, Ia. a.r'i . UOR13_C n,C; : 010 6211 311 <br /> [e: <br /> (Set]� k. , 6A, RG <br /> N <br /> (00 <br /> z 2.d# _t,ds, , a� ^.die3 , Lie(tui.tl, c3aacr ra_o.s ' � <br /> (� i Mainz xx7 x-cl s as _iasJ , 6.1, PGXXI <br /> 3, r 3 : � a F� t riGax— . mus es-: f .. r 33 <br /> 2 .2 <br /> LA <br /> 14.Special Handling Instructions and Additional Information <br /> �) Ioo e pnczlR: Taz-d±i:.i ERG t: 151 21 <br /> 3) Ast.lama Trih$jex- apK,41144 t?; ERG 0 126 <br /> 15. GENERAT013151OFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and labeledlplacarded,and are in all respects in proper condition for transport according to applicable intemationaland natlonal governmental regulations.If export shipment and I am the Primary <br /> Exporter,I cedify that the contents of this consignment conform to the terms of the attached EPAAcknowlecig nl of consam. <br /> I mldtq that the waste minimization statement Identified in 40 CFR 262.27(x)(if I am a large quantity gener or(b) ' a sq a a genorator}'s true. <br /> GeneratorsfOfferor's Prinledlryped Name Sig ura Month flayYeyar <br /> ` .. C <br /> _jents l Shipments ti <br /> 16.International import to U.S. ry <br /> � ❑ Export from U.S. Part of eni !exit: <br /> ? Transporter signature(for exports only): Date leaving U.S.: <br /> W 17,Transporter Acknowledgment of Receipt of Materials <br /> LU <br /> 12 Transporter 1 PrintedlTyped Name Signatu Month Day Year <br /> a. ± <br /> Transporter 2 Printedffyped Name Signature Month Day Year <br /> r <br /> 18.Discrepancy rr� <br /> 18x.Discrepancy Indication Spam ❑ Quantity ❑Type ❑Residue f arhal Rejection ❑Full Rejection <br /> Manifest Reference Number; <br /> per., 18b.Alternate Facility(or Generator} U.S.EPA ID Number <br /> .:t <br /> t1 <br /> Facility's Phone: <br /> 18c.Slgnalure of Alternate Facility(or Generator) Month pay Year <br /> 19.Hazardous Waste Report Management Method Codes(Le.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> t 2. 3. 14. <br /> 20.Designated Facility Owner or Oporalon Certification of receipt of hazardous materials covered by the manifest excel as nded in Item 16a <br /> PrinledlTyped Name Signature Month Day Year <br /> SPA Farm 2 R ,12-17) Previous editions are obsolete. BIGNATE0 FACILITY TO EPA's s-MANIFEST SYSTEM <br />